The nurse observes the following rhythm of a client on the telemetry unit.
Which action should be completed first?
Report the findings and anticipate a medical prescription for amiodarone
Initiate a rapid response call and increase the monitor's sensitivity
Start compressions and prepare for defibrillation
Establish unresponsiveness and check the carotid pulse
The Correct Answer is D
A. Reporting the findings and anticipating a prescription for amiodarone may be necessary later, but the first step is to assess the patient's immediate condition (unresponsiveness, pulse status, etc.).
B. Although increasing monitor sensitivity and initiating a rapid response call might be helpful, these actions come after assessing the patient’s condition. If the patient is in distress or unresponsive, the nurse needs to check for a pulse and intervene right away.
C. This is a crucial action if the patient is unresponsive and pulseless (cardiac arrest). If the patient is found to be unresponsive and pulseless, starting chest compressions immediately and preparing for defibrillation is the next step. However, the first action is to check for pulse and responsiveness.
Why it's incorrect: Compressions and defibrillation are correct actions if the patient is pulseless, but before taking these steps, the nurse must assess the patient for responsiveness and check the carotid pulse. Starting CPR and preparing defibrillation without verifying the patient's condition could delay appropriate care.
D. Checking responsiveness and pulse is the most immediate and critical action because VT may be asymptomatic or cause deterioration, including cardiac arrest. Once pulse and responsiveness are determined, appropriate interventions (such as defibrillation or CPR) can be initiated quickly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Giving away valued possessions - This is a classic sign of suicidal ideation, as individuals may feel they no longer need their belongings or want to say goodbye to loved ones in a symbolic way.
B. Engaging in high-risk behaviors - While high-risk behaviors can be a sign of depression, they are not necessarily indicative of suicidal thoughts.
C. Talkative, with pressured speech - This could be indicative of a manic episode or high anxiety, but it is not a common sign of suicidal behavior.
D. Guilt, decreased self-esteem - Although guilt and low self-esteem are symptoms of depression, they do not directly indicate suicidal thoughts or behaviors.
Correct Answer is A
Explanation
A. A decreased D-dimer level is a positive outcome, as D-dimer is elevated in DIC due to the formation of clots and the breakdown of fibrin. Lower levels indicate less clot formation and better control of the condition.
B. Fibrinogen levels are typically low in DIC due to consumption of clotting factors. Elevated fibrinogen in this case would be a negative indicator, suggesting that clotting is not resolving.
C. A decreased platelet count is a hallmark of DIC and indicates ongoing consumption of platelets due to widespread clotting. A decrease would not be a positive outcome.
D. A prolonged PT is another indicator of DIC, suggesting impaired clotting function. This is not a positive outcome.
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